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Glossary of terms

The Uniform Glossary of Health Coverage and Medical Terms was developed as part of the health care reform Affordable Care Act by the Department of Health and Human Services, Department of Labor, and the Internal Revenue Service to meet the requirements of the Summary of Benefits and Coverage Document provision.

This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs.

  • a

    • Accountable Care Organizations

      An ACO is a local health care organization that’s held accountable for the cost and quality of the care it delivers to Wellmark members. They focus on preventive care, care coordination, and greater patient involvement. During the first two years of operation, ACOs improved quality scores by 35 percent, and saved over $12 million. Today, more than 630,000 Wellmark member receive care through 15 ACOs.
       
    • Allowed Amount

      Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)

    • Appeal

      A request for your health insurer or plan to review a decision or a grievance again.

  • b

    • Balance Billing

      When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

  • c

    • Coinsurance

      Your share of the costs of a covered health care service, calculated as a percent (for example, 20 percent) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20 percent would be $20. The health insurance or plan pays the rest of the allowed amount.

    • Complications of Pregnancy

      Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren’t complications of pregnancy.

    • Copayment

      A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

  • d

    • Deductible

      The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

    • Durable Medical Equipment (DME)

      Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

  • e

    • Emergency Medical Condition

      An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

    • Emergency Medical Transportation

      Ambulance services for an emergency medical condition.

    • Emergency Room Care

      Emergency services you get in an emergency room.

    • Emergency Services

      Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

    • Essential Health Benefits

      According to the Affordable Care Act, your EHB are services which must be covered for any fully-insured, non-grandfathered health plans for individuals and small groups. They include:

      • Ambulatory patient services 
      • Emergency services
      • Hospitalization
      • Maternity and newborn care
      • Mental health and substance use disorder services, including behavioral health treatment
      • Prescription drugs
      • Rehabilitative and habilitative services and devices
      • Laboratory services
      • Pediatric services, including oral and vision care
      • Preventive and wellness services and chronic disease management

      Since EHBs are required, you may see an increase in these types of services.

    • Excluded Services

      Health care services that your health insurance or plan doesn’t pay for or cover.

  • f

    • Flexible Spending Account

      FSAs work with qualifying plans, and you cannot have both an FSA and HSA with the same plan. With the funds from a Health Care FSA, you can pay for doctor visits, prescriptions and a wide range of other medical services with tax-free money. This means you’ll pay less in taxes and take home more of your paycheck. For example, if you’re in the 25% tax bracket, you’ll save $25 on every $100 you spend.
  • g

    • Grievance

      A complaint that you communicate to your health insurer or plan.

  • h

    • Habilitation Services

      Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

    • Health Insurance

      A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

    • Health Maintenance Exam (HME)

      It’s commonly known as a “routine” or “annual” physical. Your health benefits, however, might not cover yearly physicals. Instead, your benefits could cover periodic health maintenance exams. The (HME) guidelines are based on recommendations from the American Academy of Pediatrics, the American Academy of Family Practice, the American College of Obstetrics and Gynecology, and the Center for Disease Control, among others. Be sure to review the guidelines annually.
    • Health Savings Account

      An HSA allows you to pay for qualified medical expenses, like doctor visits and prescription drugs, tax-free. Each year, you can contribute pre-tax dollars to your HSA. The numbers can change year-to-year for individuals and families. If you're 55 or older, you can make a higher contribution. If you don't use all the money in your HSA, it automatically rolls over to the next year and continues to accumulate. Plus, the interest on the money in your account is also tax-free.
    • HMO

      Wellmark’s Health Maintenance Organization (HMO) plans give you access to 100% of hospitals and 96% of doctors in Iowa, who agree to meet quality standards at lower rates for members. Out-of-state coverage is available in emergency and accidental injury situations.
    • Home Health Care

      Health care services a person receives at home.

    • Hospice Services

      Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

    • Hospitalization

      Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

    • Hospital Outpatient Care

      Care in a hospital that usually doesn’t require an overnight stay.

  • i

    • Initial Enrollment Period (IEP)

      The Initial Enrollment Period for Medicare Parts A and B starts 3 months before the month of your 65th birthday and ends 3 months after the month of eligibility.
    • In-Network Coinsurance

      The percent (for example, 20 percent) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.

    • In-Network Copayment

      A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.

  • m

    • Medically Necessary

      Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

  • n

    • Network

      The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

    • Non-Preferred Provider

      A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

  • o

    • Out-of-Network Coinsurance

      The percent (for example, 40 percent) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

    • Out-of-Network Copayment

      A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.

    • Out-of-Pocket Costs

      All costs of care not covered by your plan are considered out-of-pocket costs. They include co-insurance, co-payments, deductibles and any other uncovered costs.
    • Out-of-Pocket Limit

      The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100 percent of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your copayments, deductibles, coinsurance payments, out-of-network payments or other expenses toward this limit.

  • p

    • Physician Services

      Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

    • Plan

      A benefit your employer, union or other group sponsor provides to you to pay for your health care services.

    • POS

      Point of Services (POS) plans combine elements of both HMO and PPO plans with varying benefit levels depending on whether the providers are in- or out-of-network.
    • PPO

      Preferred Provider Organization (PPO) plans offer more flexibility to members when choosing a doctor or hospital. Members can reduce their out-of-pocket costs when they choose a network provider.
    • Preauthorization

      A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

    • Preferred Provider

      A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

    • Premium

      The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

    • Prescription Drug

      Drugs and medications that by law require a prescription.

    • Prescription Drug Coverage

      Health insurance or plan that helps pay for prescription drugs and medications.

    • Primary Care Physician

      A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

    • Primary Care Provider

      A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

    • Prior Authorization

      Some services and procedures require a pre-service review before receiving care. The reason for this is to ensure you get the right care at the right time, take the right medications, and that the care meets evidence-based guidelines. Wellmark has an Authorization Table to help you and your provider understand our pre-authorization requirements. By gaining pre-authorization, you can avoid unexpected medical bills. 
    • Provider

      A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.

  • r

    • Reconstructive Surgery

      Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.

    • Rehabilitation Services

      Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

  • s

    • Skilled Nursing Care

      Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

    • Specialist

      A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

    • Summary of Benefits Coverage (SBC)

      The SBC helps you better understand and compare your coverage options. The summaries use a standard format, so it’s easier to make those comparisons. They outline the medical care and prescription benefits health plans cover, including health benefits, costs, limitation and exceptions, and network provider information.
  • u

    • UCR (Usual, Customary and Reasonable)

      The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

    • Underwriting

      Review of an individual's medical background in order to qualify them for health insurance.

    • Urgent Care

      Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

  • w

    • Wellmark Blue HMO

      Our Health Maintenance Organization network—the Wellmark Blue HMO℠—covers every hospital in Iowa and 96 percent of the doctors. Plus, it offers members lower premiums and excellent care. Your share of the costs will vary depending on the plan you choose.